Can postural changes in spirometry in children with Duchenne muscular dystrophy predict sleep hypoventilation?

AIM

To explore the relationship between postural changes in lung function and polysomnography (PSG) in children with Duchenne muscular dystrophy (DMD).

METHODS

In this prospective cross-sectional study, children with DMD performed spirometry in sitting and supine positions. A control group of age and gender matched healthy children also underwent postural lung function testing. PSG was performed within six months of spirometry.

RESULTS

Seventeen children with DMD, aged 12.3 ± 3 years performed sitting spirometry. 14 (84%) performed acceptable spirometry in the supine position. Mean FEV1sit and FVCsit were 77% (SD ± 22) and 74% (SD ± 20.4) respectively, with mean% ΔFVC(sit-sup) 9% (SD ± 11) (range 2% to 20%), and was significantly greater than healthy controls 4% (n = 30, SD ± 3, P < 0.001). PSG data on the 14 DMD children with acceptable supine spirometry showed total AHI 6.9 ± 5.9/hour (0.3 to 29), obstructive AHI 5.2 ± 4.0/hour (0.2 to 10), and REM AHI 14.1 ± -5.3/hour (0.1 to 34.7). ΔFVC(sit-sup) had poor correlation with hypoventilation on polysomnography.

CONCLUSION

Children with DMD and mild restrictive lung disease showed greater postural changes in spirometry than healthy controls but lower supine spirometry was not predictive of sleep hypoventilation.

Findings from three methods to identify falls in hospitals: Results from the Ambient Intelligent Geriatric Management system fall prevention trial

OBJECTIVE

To (a) compare characteristics of patients who fall with those of patients who did not fall; and (b) characterise falls (time, injury severity and location) through three fall reporting methods (incident system reports, medical notes and clinician reports).

METHODS

A substudy design within a stepped-wedge clinical trial was used: 3239 trial participants were recruited from two inpatient Geriatric Evaluation and Management Units and one general medicine ward in two Australian states. To compare the characteristics of patients who had fallen with those who had not, descriptive tests were used. To characterise falls through three reporting methods, bivariate logistic regressions were used.

RESULTS

Patients who had fallen were more likely than patients who had not fallen to be cognitively impaired (51% vs. 29%, p < 0.01), admitted with falls (38% vs. 28%, p = 0.01) and have poor health outcomes such as prolonged length of stay (24 [16-34] vs. 12 [8-19] days [IQR], p < 0.01) and less likely to be discharged directly to the community (62% vs. 47%, p < 0.01). Most falls were captured from medical notes (93%), with clinician (71%) and incident reports (68%) missing 21%-25% of falls. The proportion of injurious falls identified through incident reports was higher than medical records or clinician reports (40% vs. 34% vs. 37%).

CONCLUSIONS

This study reaffirms the need to improve reporting falls in incident systems and at clinical handover to the team leader. Research should continue to use more than one method of identifying falls, but include data from medical records. Many falls cause injury, resulting in poor health outcomes.

The oral health of adults with learning disabilities: A secondary analysis of the Adult Dental Health Survey 2009

OBJECTIVES

Adults who have learning disabilities are a vulnerable group, little is known about their oral health and how this affects their quality of life. The aims of this secondary analysis of data from the 2009 Adult Dental Health Survey (ADHS) were to describe the oral health status of adults with learning disabilities, determine if severity of learning disability is associated with oral health and identify some of the methodological complexities of working with this population. The survey yields the most recent representative data on the oral health of adults with learning disabilities in England and importantly, contains information about oral health related quality of life (OHRQoL).

BASIC RESEARCH DESIGN

Secondary analysis of data from a supplemental survey of adults with learning disabilities collected alongside the 2009 ADHS.

PARTICIPANTS

607 participants with a diagnosed learning disability aged 18 years and over.

RESULTS

Adults with learning disabilities had similar levels of active dental caries, fewer natural teeth, and fewer fillings than comparable participants from the general population. Self-reported oral and general health were worse for adults with learning disabilities than the general population. Possible associations between the severity of learning disability and the numbers of decayed, missing or filled teeth were identified. However, large amounts of missing data limited the analysis.

CONCLUSIONS

There are important questions relating to the accessibility of existing self-reported oral health questionnaires and the reliability of proxy-reported questions about OHRQoL that should be addressed to give a fuller picture of the oral health of adults with learning disabilities.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Factors influencing occupational exposure to pyrethroids and glyphosate: An analysis of urinary biomarkers in Malaysia, Uganda and the United Kingdom

BACKGROUND

Long-term exposure to pesticides is often assessed using semi-quantitative models. To improve these models, a better understanding of how occupational factors determine exposure (e.g., as estimated by biomonitoring) would be valuable.

METHODS

Urine samples were collected from pesticide applicators in Malaysia, Uganda, and the UK during mixing/application days (and also during non-application days in Uganda). Samples were collected pre- and post-activity on the same day and analysed for biomarkers of active ingredients (AIs), including synthetic pyrethroids (via the metabolite 3-phenoxybenzoic acid [3-PBA]) and glyphosate, as well as creatinine. We performed multilevel Tobit regression models for each study to assess the relationship between exposure modifying factors (e.g., mixing/application of AI, duration of activity, personal protective equipment [PPE]) and urinary biomarkers of exposure.

RESULTS

From the Malaysia, Uganda, and UK studies, 81, 84, and 106 study participants provided 162, 384 and 212 urine samples, respectively. Pyrethroid use on the sampling day was most common in Malaysia (n = 38; 47%), and glyphosate use was most prevalent in the UK (n = 93; 88%). Median pre- and post-activity 3-PBA concentrations were similar, with higher median concentrations post-compared to pre-activity for glyphosate samples in the UK (1.7 to 0.5 μg/L) and Uganda (7.6 to 0.8 μg/L) (glyphosate was not used in the Malaysia study). There was evidence from individual studies that higher urinary biomarker concentrations were associated with mixing/application of the AI on the day of urine sampling, longer duration of mixing/application, lower PPE protection, and less education/literacy, but no factor was consistently associated with exposure across biomarkers in the three studies.

CONCLUSIONS

Our results suggest a need for AI-specific interpretation of exposure modifying factors as the relevance of exposure routes, levels of detection, and farming systems/practices may be very context and AI-specific.

Human biomonitoring and toxicokinetics as key building blocks for next generation risk assessment

Human health risk assessment is historically built upon animal testing, often following Organisation for Economic Co-operation and Development (OECD) test guidelines and exposure assessments. Using combinations of human relevant in vitro models, chemical analysis and computational (in silico) approaches bring advantages compared to animal studies. These include a greater focus on the human species and on molecular mechanisms and kinetics, identification of Adverse Outcome Pathways and downstream Key Events as well as the possibility of addressing susceptible populations and additional endpoints. Much of the advancement and progress made in the Next Generation Risk Assessment (NGRA) have been primarily focused on new approach methodologies (NAMs) and physiologically based kinetic (PBK) modelling without incorporating human biomonitoring (HBM). The integration of toxicokinetics (TK) and PBK modelling is an essential component of NGRA. PBK models are essential for describing in quantitative terms the TK processes with a focus on the effective dose at the expected target site. Furthermore, the need for PBK models is amplified by the increasing scientific and regulatory interest in aggregate and cumulative exposure as well as interactions of chemicals in mixtures. Since incorporating HBM data strengthens approaches and reduces uncertainties in risk assessment, here we elaborate on the integrated use of TK, PBK modelling and HBM in chemical risk assessment highlighting opportunities as well as challenges and limitations. Examples are provided where HBM and TK/PBK modelling can be used in both exposure assessment and hazard characterization shifting from external exposure and animal dose/response assays to animal-free, internal exposure-based NGRA.

Australian Patient Preferences for Discussing Spiritual Issues in the Hospital Setting: An Exploratory Mixed Methods Study

While there is high patient acceptance for clinical staff discussing issues regarding spirituality with hospital inpatients, it is not clear which staff member patients prefer for these discussions. This unique exploratory study investigated inpatient preferences regarding which staff member should raise the topic of spirituality. A cross-sectional survey was conducted with inpatients at six hospitals in Sydney, Australia (n = 897), with a subset invited to participate in qualitative interviews (n = 41). Pastoral care staff (32.9%) were the preferred staff members with whom to discuss spiritual issues, followed by doctors (22.4%). Qualitative findings indicated that individual characteristics of the staff member are more important than their role.

Self-reported and urinary biomarker-based measures of exposure to glyphosate and mancozeb and sleep problems among smallholder farmers in Uganda

OBJECTIVE

We aim to showcase the impact of applying eight different self-reported and urinary biomarker-based exposure measures for glyphosate and mancozeb on the association with sleep problems in a study among 253 smallholder farmers in Uganda.

METHODS

The questionnaire-based exposure measures included: (1) the number of application days of any pesticide in the last 7 days (never, 1-2; >2 days) and six glyphosate and mancozeb-specific measures: (2) application status over the last 12 months (yes/no), (3) recent application status (never, last 7 days and last 12 months), (4) the number of application days last 12 months, (5) average exposure-intensity scores (EIS) and (6) EIS-weighted number of application days in last 12 months. Based on 384 repeated urinary biomarker concentrations of ethylene thiourea (ETU) and glyphosate from 84 farmers, we also estimated (7) average biomarker concentrations for all 253 farmers. Also in the 84 farmers the measured pre-work and post-work biomarker concentrations were used (8). Multivariable logistic regression models were used to assess the association between the exposure measures and selected Medical Outcomes Study Sleep Scale (MOS-SS) indices (6-item, sleep inadequacy and snoring).

RESULTS

We observed positive associations between (1) any pesticide application in the last 7 days with all three MOS-SS indices. Glyphosate application in the last 7 days (3) and mancozeb application in the last 12 months (3) were associated with the 6-item sleep problem index. The estimated average urinary glyphosate concentrations showed an exposure-response association with the 6-item sleep problem index and sleep inadequacy in the same direction as based on self-reported glyphosate application in the last 7 days. In the analysis with the subset of 84 farmers, both measured and modelled post-work urinary glyphosate concentration showed an association with snoring.

CONCLUSIONS

Self-reported, estimated average biomarker concentrations and measured urinary biomarker exposure measures of glyphosate and mancozeb showed similar exposure-response associations with sleep outcomes.

Nelson syndrome and perinatal challenges: A case report and systematic review of the literature

Nelson syndrome is a rare and potentially life-threatening complication of treatment with total bilateral adrenalectomy for women with Cushing disease. A successful term pregnancy following fertility treatment in a patient with Nelson syndrome is presented. Our study provides guidance in the prenatal and intrapartum management of this condition. A case report and a systematic review of 14 papers describing 50 pregnancies are presented. An electronic database search included Medline (1946 to September 2022), Embase (1980 to September 2022), Cochrane Library, and UKOSS. A small number of pregnancies in women with Nelson syndrome are reported in literature, but there are no guidelines. Some authors detail the prenatal care provided to their patients. Four studies report prenatal monitoring with visual field checks and two report monitoring with X-rays. Five studies report the use of parenteral hydrocortisone at the time of delivery. Where described, women delivered appropriately grown newborns at term, with timing and mode of delivery dictated by obstetric indications. Preconception counseling and optimization of maternal health status improve pregnancy outcomes in women with Nelson syndrome. Multidisciplinary review in a combined obstetric-endocrine prenatal clinic is ideal. Awareness about potential complications during pregnancy and the postnatal period is crucial in providing optimal care to the mother and baby.

Prognostic Value of Weekly Delta-Radiomics during MR-Linac Radiotherapy of Glioblastoma

PURPOSE/OBJECTIVE(S)

MRI after chemoradiotherapy (chemoRT) shows areas of presumed tumor growth in ≤ 50% of glioblastoma (GBM) patients, which can be true progression (TP) - tumor growth with poor treatment response, or pseudoprogression (PP) - edema and tumor necrosis with favorable treatment response. Patients with TP have median overall survival (OS) of only 7 months, while patients with PP have median OS of 36 months. However, on imaging, TP and PP are usually not discernible during treatment, making it difficult to adapt radiation for poor responders. The purpose of this study was to investigate the prognostic value of delta radiomic features from MR-Linac for GBM.

MATERIALS/METHODS

Using an IRB-approved prospective cohort of GBM patients undergoing 30 fractions of chemoRT to 60 Gy on a 0.35T MR-Linac, 2 regions of interest (ROI) were contoured on daily T2-weighted treatment set-up scans: 1) tumor/edema (lesion) and 2) post-surgical resection cavity (RC). The lesion ROI were used to calculate texture features: second order radiomics features based on the gray-level co-occurrence matrix (GLCM), gray-level size zone matrix (GLSZM), gray-level run length matrix (GLRLM), and neighborhood gray-tone difference matrix (NGTDM). Each of these describe the probability of spatial relationships of gray levels occurring within the ROI. Features from fraction 1 (pre-radiation) were subtracted from fractions 5, 10, 15, 25, and 30 to create delta features at 5 timepoints (D5-D30). Patient response was retrospectively defined as no progression (NP), TP, or PP. Supervised machine learning was utilized using a 500-tree random forest (RF) classification model with TP or PP as the outcome. Variable importance analysis was conducted by calculating the out-of-bag errors with multiple bootstrapped data sets. The most prognostic features were selected using the RF importance scores.

RESULTS

Thirty-six patients were screened for inclusion: 9 were excluded due to no T2 lesion (RC ROI only). Of the remaining 27 patients: 10 had NP, 11 had TP, and 6 had PP. Thirty-nine texture features, plus lesion volume and mean lesion intensity (for a total of 41 variables per time point) were calculated and included in the model. Of the 10 most prognostic features, 6 were from D10, suggesting that prognostic changes in the underlying lesion microenvironment are occurring within the first 10 fractions of treatment. The model selected GLSZM high gray-level zone emphasis (HGZE) D10, IBSI code 5GN9, as the most prognostic feature. The receiver operator characteristic (ROC) area under the curve (AUC) for GLSZM HGZE D10 was 0.94 (95% CI = 0.81-1.00).

CONCLUSION

Delta radiomic features extracted from MR-Linac imaging may predict between PP and TP in GBM patients during treatment, which is earlier than current methods. This could allow physicians to adapt/intensify treatment in real time for poorly responding patients. Future directions include analysis with a larger patient cohort and with additional MRI contrasts (MR-Linac multiparametric MRI).

Pattern Analysis of Daily Lesion Volume Trajectories for Early Prediction of Glioblastoma Progression During MR-Linac Radiotherapy

PURPOSE/OBJECTIVE(S)

Distinguishing between true progression (TP) and pseudoprogression (PP) post-radiotherapy (RT) is of paramount importance for treatment management of patients with glioblastoma (GBM). MR-Linac systems allow for daily monitoring of tumor changes throughout the course of RT. We hypothesized that the patterns of tumor volume change during RT may enable early prediction of treatment response.

MATERIALS/METHODS

Using an IRB-approved prospective cohort of GBM patients undergoing 30 fractions of chemoRT to 60 Gy on a 0.35T MR-Linac, tumor/edema (tumor lesion) regions of interest (ROI) were contoured on daily T2-weighted treatment set-up scans. The obtained tumor lesion (TL) volume changes during treatment were smoothed with a moving average Gaussian window over time. Non-negative Matrix Factorization (NMF) was applied to the data matrix D (N x F), containing the trajectories in its rows for each patient, where N is the number of patients analyzed and F is the number of fractions. NMF represents D as a linear combination of three temporal (hidden) patterns and their weights in each individual trajectory. The same analysis was performed for ΔD, containing the changes in volumes with reference to the first fraction. The calculated weights were scaled in [0, 1], expressed as probabilities (by ℓ1-normalization) and used as features in Linear Discriminant Analysis (LDA). The LDA model was trained to differentiate between no progression (NP), PP and TP, and assessed by leave-one-subject-out cross-validation.

RESULTS

Thirty-six patients were screened for inclusion: 9 were excluded due to no T2 lesion (resection cavity only). Of the remaining 27 GBM patients analyzed, 10 had no tumor growth on first post-RT diagnostic MRI, 6 were determined to have PP based on regression or long-term stability of findings, and 11 had TP due to continued progression of disease past 6 months, rapid patient death from disease, or tissue sampling showing active malignancy. With the use of only 2 features, LDA achieved an overall accuracy of 70.4% classifying correctly: 6 (60%), 4 (67%), and 9 (82%) patients with NP, PP, and TP, respectively. The temporal NMF patterns (monotonous decrease, rapid increase during the third part of the treatment, etc.) indicate that there is enough signal to classify patients' response based on the pattern tumor volume changes during RT.

CONCLUSION

We identified tumor dynamics' patterns during RT, indicative of differential behavior of tumor growth between TP and PP. Although with a limited number of patients, these initial results suggest that tumor volume changes during treatment may provide early markers of treatment response. This could allow physicians to adapt/intensify treatment in real time for poorly responding patients. Next steps include automating the process of real-time tumor volume monitoring by incorporating a deep learning solution for automatic volume delineation on daily treatment set-up scans.

A novel COVID-19 program, delivering vaccines throughout rural and remote Australia

Background

The Royal Flying Doctor Service of Australia (RFDS) established a unique SARS-CoV-2 vaccination program for vaccinating Australians that live in rural and remote areas. This paper describes the preparation and response phases of the RFDS response.

Methods

This study includes vaccinations conducted by the RFDS from 01 January 2021 until 31 December 2021 when vaccines were mandatory for work and social activities. Prior to each clinic, we conducted community consultation to determine site requirements, patient characteristics, expected vaccination numbers, and community transmission rates.

Findings

Ninety-five organizations requested support. The majority (n = 60; 63.2%) came from Aboriginal Community Controlled Health Organizations. Following consultation, 360 communities were approved for support. Actual vaccinations exceeded expectations (n = 70,827 vs. 49,407), with a concordance correlation coefficient of 0.88 (95% CI, 0.83, 0.93). Areas that reported healthcare workforce shortages during the preparation phase had the highest population proportion difference between expected and actual vaccinations. Areas that reported high vaccine hesitancy during the preparation phase had fewer than expected vaccines. There was a noticeable increase in vaccination rates in line with community outbreaks and positive polymerase chain reaction cases [r (41) = 0.35, p = 0.021]. Engagement with community leaders prior to clinic deployment was essential to provide a tailored response based on community expectations.

The oral health of adults attending dental practices in England in 2018: a report of a novel method and findings

Introduction National surveys of the oral health of adults are conducted decennially. For reasons of feasibility and cost, these only provide accurate information at large geographical areas. To address this, a survey of adults attending dental practices in England was undertaken.Aim To describe and discuss the survey method and findings.Method A clinical examination and questionnaire survey was conducted in a sample of English dental practices.Results Questionnaires (n = 16,572) and clinical examinations (n = 14,270) were completed with patients from 1,173 dental practices. Poorer oral health disproportionately affected older adults and those from more socioeconomically deprived areas. Over one in three from more deprived areas had untreated caries compared with one in five in the less deprived (36.2% vs 19.9%) and impacts of oral problems were nearly three times higher in the more deprived areas (27.9% vs 11.0%). Of those receiving NHS care, 28.7% and 46.2% reported they would struggle/be unable to pay a Band 2 and Band 3 NHS patient charge, respectively.Conclusion It is feasible to undertake a survey of adults in dental practices but care must be taken generalising the findings to the general population and comparing them with other surveys undertaken using different methods.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Children's Experiences of Death Anxiety and Responses to the Covid-19 Pandemic

The aim of this study was to explore children's experience and responses to the Covid-19 pandemic through their illustrations and short narrations. During October 2020 and January 2021 data was collected from thirteen children aged 9-10 years old in a primary school in the North-West of England. Children were asked to draw their thoughts and feelings about the pandemic and to write a short narration to accompany the drawing. Thematic analysis of data revealed that during the pandemic children at this age have an understanding of death, experience death anxiety and are able to use creative expression to facilitate meaning of the impact of lockdown on their lives such as feeling isolated, lonely, sad and bored. Creative expression also facilitated adaptive coping mechanisms derived from being able to spend more time with family. The data on primary school children is part of a larger study which involved surveys and interviews with children aged 12-16 years in secondary schools.

Development and Validation of the Hospital-to-Home-Health Transition Quality (H3TQ) Index: A Novel Measure to Engage Patients and Home Health Providers in Evaluating Hospital-to-Home Care Transition Quality

BACKGROUND

Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions.

OBJECTIVE

To describe the development, initial psychometric validation, and feasibility of the Hospital-to-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks.

METHODS

Development: A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing: Prospective H3TQ implementation on older adults' hospital-to-HH transitions. Populations Studied: Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists).

RESULTS

The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients' lack of general understanding of care plans (27%).

CONCLUSIONS

The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition.

FAIR environmental and health registry (FAIREHR)- supporting the science to policy interface and life science research, development and innovation

The environmental impact on health is an inevitable by-product of human activity. Environmental health sciences is a multidisciplinary field addressing complex issues on how people are exposed to hazardous chemicals that can potentially affect adversely the health of present and future generations. Exposure sciences and environmental epidemiology are becoming increasingly data-driven and their efficiency and effectiveness can significantly improve by implementing the FAIR (findable, accessible, interoperable, reusable) principles for scientific data management and stewardship. This will enable data integration, interoperability and (re)use while also facilitating the use of new and powerful analytical tools such as artificial intelligence and machine learning in the benefit of public health policy, and research, development and innovation (RDI). Early research planning is critical to ensuring data is FAIR at the outset. This entails a well-informed and planned strategy concerning the identification of appropriate data and metadata to be gathered, along with established procedures for their collection, documentation, and management. Furthermore, suitable approaches must be implemented to evaluate and ensure the quality of the data. Therefore, the 'Europe Regional Chapter of the International Society of Exposure Science' (ISES Europe) human biomonitoring working group (ISES Europe HBM WG) proposes the development of a FAIR Environment and health registry (FAIREHR) (hereafter FAIREHR). FAIR Environment and health registry offers preregistration of studies on exposure sciences and environmental epidemiology using HBM (as a starting point) across all areas of environmental and occupational health globally. The registry is proposed to receive a dedicated web-based interface, to be electronically searchable and to be available to all relevant data providers, users and stakeholders. Planned Human biomonitoring studies would ideally be registered before formal recruitment of study participants. The resulting FAIREHR would contain public records of metadata such as study design, data management, an audit trail of major changes to planned methods, details of when the study will be completed, and links to resulting publications and data repositories when provided by the authors. The FAIREHR would function as an integrated platform designed to cater to the needs of scientists, companies, publishers, and policymakers by providing user-friendly features. The implementation of FAIREHR is expected to yield significant benefits in terms of enabling more effective utilization of human biomonitoring (HBM) data.

Using Virtual Home Assistants to Address Vulnerable Adults' Complex Care Needs: An Exploratory Feasibility Study

Harnessing technology has been proposed as one strategy to meet the social and health needs of older adults who prefer to age in place, but solutions remain elusive. In the current study, we evaluated the feasibility of using voice-activated virtual home assistants (VHAs; i.e., Amazon Echo "Alexa" devices) with older adults participating in the Program for All-Inclusive Care of the Elderly (PACE) over 4 months. Study methods included process evaluations, tracking participants' VHA use, and qualitative feedback from PACE participants and staff. The most common VHA activities were voice-activated smart lighting and asking for information. Participants infrequently used VHA activities that could promote physical or cognitive function (e.g., chair yoga, word recall game). Participants enjoyed using the VHAs, and PACE staff were enthusiastic about the potential for VHAs to facilitate aging in place and provided recommendations to increase participants' use of functional health activities. [Journal of Gerontological Nursing, 49(6), 33-40.].

Chaplaincy Perspectives on the Role of Spirituality in Australian Health and Aged Care

The aim of this study was to explore Australian chaplains' views of spirituality. Semi-structured online interviews were conducted with 16 participants. Participants relied heavily on metaphors and analogies to describe spirituality. Four inter-related themes were identified through reflexive thematic analysis: (1) The core of spirituality: spirituality as a source of meaning or belief which leads to connectedness with something greater than oneself; (2) A function of spirituality: spirituality empowers people to cope in a crisis, by providing motivation, hope and comfort; (3) The experience of spiritual crisis: admission to hospital or residential care can lead to existential struggle; and (4) The spiritual practice: of holding space between struggle and growth. Greater understanding of the theoretical basis of their work may allow chaplains to offer more in the therapeutic space.

A physiologically-based kinetic (PBK) model for work-related diisocyanate exposure: Relevance for the design and reporting of biomonitoring studies

Diisocyanates are highly reactive substances and known causes of occupational asthma. Exposure occurs mainly in the occupational setting and can be assessed through biomonitoring which accounts for inhalation and dermal exposure and potential effects of protective equipment. However the interpretation of biomonitoring data can be challenging for chemicals with complex kinetic behavior and multiple exposure routes, as is the case for diisocyanates. To better understand the relation between external exposure and urinary concentrations of metabolites of diisocyanates, we developed a physiologically based kinetic (PBK) model for methylene bisphenyl isocyanate (MDI) and toluene di-isocyanate (TDI). The PBK model covers both inhalation and dermal exposure, and can be used to estimate biomarker levels after either single or chronic exposures. Key parameters such as absorption and elimination rates of diisocyanates were based on results from human controlled exposure studies. A global sensitivity analysis was performed on model predictions after assigning distributions reflecting a mixture of parameter uncertainty and population variability. Although model-based predictions of urinary concentrations of the degradation products of MDI and TDI for longer-term exposure scenarios compared relatively well to empirical results for a limited set of biomonitoring studies in the peer-reviewed literature, validation of model predictions was difficult because of the many uncertainties regarding the precise exposure scenarios that were used. Sensitivity analyses indicated that parameters with a relatively large impact on model estimates included the fraction of diisocyanates absorbed and the binding rate of diisocyanates to albumin relative to other macro molecules.We additionally investigated the effects of timing of exposure and intermittent urination, and found that both had a considerable impact on estimated urinary biomarker levels. This suggests that these factors should be taken into account when interpreting biomonitoring data and included in the standard reporting of isocyanate biomonitoring studies.

Rehabilitation for people wearing offloading devices for diabetes-related foot ulcers: a systematic review and meta-analyses

BACKGROUND

Offloading devices improve healing of diabetes-related foot ulcers (DFUs) but they can limit mobilisation. Rehabilitation during or after removal of these devices may promote physical activity in a population at risk of poor health outcomes for which inactivity is a reversible risk factor.

METHODS

This systematic review examined the effectiveness of rehabilitation interventions to promote physical activity during and/or after wearing an offloading device to treat diabetes-related foot ulcers. Searches using MESH terms and free-text combinations: 'foot ulcer', 'diabetic foot', 'casts, surgical', 'orthotic devices' were applied to MEDLINE, Embase, The Cochrane Library and clinical trial registers for randomised and observational studies published to September 2022. Methodological quality assessment of included studies was undertaken using the Cochrane Risk of Bias (RoB 2.0) and Risk of Bias In Non-randomised studies of Interventions (ROBINS-I) tools.

RESULTS

Of 3332 records identified, eight studies (441 participants), four clinical trials and four cohort studies, were included. None delivered or tested a structured rehabilitation programme, but all reported physical activity outcomes during or after device use. People wearing non-removable total contact casts were less active than those wearing devices (SMD -0.45; 95% CI - 0.87 to - 0.04; p = 0.03; I² 56%; 4 trials). Diabetes-related foot ulcers in people wearing total contact casts were more likely to heal compared to removable devices at 12 weeks (OR 2.69; 95% CI 0.97 to 7.45; p = 0.06; I² = 64%; 4 trials) and 20 weeks (OR 2.35; 95% CI 0.95 to 5.82; p = 0.07; I² = 65%; 4 trials).

CONCLUSIONS

Despite physical activity being low throughout off-loading treatment, no studies have specifically tested rehabilitation. There is a need to investigate the clinical and cost-effectiveness of rehabilitation programmes in this population. High quality trials are needed to provide robust evidence to support to rehabilitation after DFU treatment.

The HBM4EU chromates study - Outcomes and impacts on EU policies and occupational health practices

Within the EU human biomonitoring initiative (HBM4EU), a targeted, multi-national study on occupational exposure to hexavalent chromium (Cr(VI)) was performed. Cr(VI) is currently regulated in EU under REACH (Registration, Evaluation, Authorisation and Restriction of Chemicals) and under occupational safety and health (OSH) legislation. It has recently been subject to regulatory actions to improve its risk management in European workplaces. Analysis of the data obtained within the HBM4EU chromates study provides support both for the implementation of these regulatory actions and for national enforcement programs and may also contribute to the updating of occupational limit values (OELs) and biological limit values for Cr(VI). It also provides useful insights on the contribution of different risk management measures (RMMs) to further reduce the exposure to Cr(VI) and may support the evaluation of applications for authorisation under REACH. Findings on chrome platers' additional per- and polyfluoroalkyl substances (PFAS) exposure highlight the need to also pay attention to this substance group in the metals sector. A survey performed to evaluate the policy relevance of the HBM4EU chromates study findings supports the usefulness of the study results. According to the responses received from the survey, the HBM4EU chromates study was able to demonstrate the added value of the human biomonitoring (HBM) approach in assessment and management of occupational exposure to Cr(VI). For future occupational studies, we emphasise the need for engagement of policy makers and regulators throughout the whole research process to ensure awareness, relevance and uptake of the results in future policies.

Effectiveness of strategies to increase participation in school-based epidemiological surveys: a rapid review

OBJECTIVE

Rapid review of the literature on strategies to increase participation rates in school-based epidemiological surveys.

BASIC RESEARCH DESIGN

Rapid review. MEDLINE and Embase databases were searched for articles written in English from 2000 onwards. Synthesised evidence and primary research were included as data sources from peer reviewed journals and reports.

INTERVENTIONS

Any strategy aiming to increase participation in school-based health surveys. The comparator was usual procedure or an alternative strategy to increase participation.

MAIN OUTCOME MEASURES

Primary outcomes included participation and consent rates. Secondary outcomes were feasibility, acceptability and adverse effects.

RESULTS

The search identified 591 unique records, of which 587 were excluded. Four studies were suitable for inclusion, including one systematic review, one randomised controlled trial, one cross-sectional study and one retrospective analysis. Based on very low certainty evidence, recommendations for maximising participation rates in one systematic review of US studies included: promoting the survey to school staff, parents and students; disseminating study information using direct rather than mediated methods; offering incentives to schools, staff and participants; following up non-responders; and employing a research team member to co-ordinate and monitor recruitment. However, UK studies found that different strategies did not increase participation more than that achieved by a standard approach (delivery of covering letter/consent forms via the child with no follow-up of non-responders).

CONCLUSION

Given the lack of evidence of effectiveness of alternative strategies in the UK, additional measures beyond existing standard approaches for active consent cannot be recommended.

HBM4EU chromates study - the measurement of hexavalent and trivalent chromium in exhaled breath condensate samples from occupationally exposed workers across Europe

The aim of this study was to investigate the practicability of exhaled breath condensate (EBC) as a biological matrix to detect and measure hexavalent chromium (Cr(VI)) and trivalent chromium (Cr(III)) in workers occupationally exposed to Cr(VI). EBC samples were collected from workers in France, Finland, Italy, The Netherlands and the United Kingdom from three different target activities: chrome platers, stainless steel welders and surface treatment workers. Pre and post working week EBC samples were collected from 177 exposed workers and 98 unexposed workers (control group). Hyphenated chromatography systems with inductively coupled plasma - mass spectrometry (ICP-MS) were for the analysis. The results showed that the occupationally exposed workers had significantly higher levels of Cr(VI) and Cr(III) than the control group. Chrome platers exhibited the highest Cr(VI) levels in their EBC samples, with a significant increase from their pre to post samples for both Cr(VI) and Cr(III). A significant difference was also found between pre and post EBC samples for Cr(III) in welders. This study has shown that EBC has the potential to be a valid, non-invasive biological matrix to assess occupational exposure to Cr(VI) and Cr(III) for biological monitoring assessment, with the ability to detect low level inhalation exposures.

Oral and maxillofacial injuries associated with e-scooter use at Broomfield Hospital: a cohort study of 24 months of data since e-scooter legalisation in the UK

Introduction Rental electronic scooters (e-scooters) were legalised in July 2020 in the UK for use on public roads. This has led to higher numbers of emergency department (ED) attendances for head and neck injuries managed by the oral and maxillofacial surgical (OMFS) department.Aim The aim of this research is to assess the increase in e-scooter injuries requiring OMFS input and analyse factors and management associated.Method Data were collected over a 24-month period. A total of 212 e-scooter-related ED presentations were recorded, with 34 patients requiring input from the OMFS department. For the patients referred to OMFS, numerical and categorical factors used independent T-tests and one-way Analysis of Variance tests, respectively, to determine statistical significance at the 5% confidence level (p <0.05).Results The mean age was 32.8 years (SD = 15.9) in a predominately male cohort (79.4%). Alcohol intoxication was observed in 55.8% of accidents. Injuries were most common on Saturdays (41.2%). Soft tissue injuries were present in 64.7% of patients, bony injuries in 38.2% of patients and dental injuries in 11.8% of patients. Imaging was required for 76.5% of patients. In total, 44% of patients required surgical treatment, 5.9% required major surgery and 38.2% required minor surgery.Conclusion This research supports the literature suggesting significant growth in e-scooter-related injuries and their associated burden of conditions managed by the OMFS department.

1307 IMPLEMENTING THE HEE COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) FOR FALLS IN CARE HOME PATIENTS– A QUALITY IMPROVEMENT PROJECT

Introduction

According to the Health Education England (HEE) Framework for Enhanced Health in Care Homes 2020, 33% of people over 65 and 50% of people over 80 have one or more fall a year, figures which significantly increase in care home residents. Prevention of falls promotes the quality of life of elderly patients and could significantly reduce the burden on primary and secondary care stemming from fall induced fractures, loss of mobility and community follow up. The Comprehensive Geriatric Assessment (CGA) for falls includes a full falls assessment questionnaire, medication review, lying/standing blood pressure and frailty index. The HEE set out a requirement that all care home patients should have a CGA assessment within 7 days of readmission to a care home following a hospital episode because of a fall. This audit examined the compliance of Four Counties primary care network (PCN) to the 7-day CGA HEE guideline for falls.

Methods

Retrospective analysis of 68 eligible patients from Four Counties PCN between 31st March 2021 and 1st March 2022. Analysis indicated a poor compliance to the HEE CGA guidelines (15%). After presenting to the MDT, we formulated a system-wide plan to improve reporting of care home falls to OTs, creating protected time for pharmacists to conduct care home medication reviews and promoting in-person weekly care-coordinator meetings. The PCN was audited for a second time after 3 months.

Results

A significant improvement (15% to 57%) in adherence to the HEE CGA framework was noted after implementation of above changes. Medication review in 7 days improved from 42% to 80% and falls assessment questionnaire in 7 days compliance improved from 23% to 70%.

Conclusion

Creating clear protocols for reporting falls and clarifying MDT roles in the CGA are essential to identifying and preventing falls in at-risk care home residents.

A Scoping Review of the Psychological and Emotional Impact of the COVID-19 Pandemic on Children and Young People

BACKGROUND

The COVID-19 pandemic has resulted in many changes to the lives of children and young people. Our aim is to explore the impact of the pandemic on the mental health of children and young people (ages 5-21).

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines was used to report the findings of this rapid review.

RESULTS

Children and young people are potentially very vulnerable to the emotional impact of traumatic events that disrupt their daily lives. Key areas of concern include: Death Anxiety and Fear of Infection; lack of social interaction and loss of routine.

CONCLUSIONS

Despite some early and responsive studies, the evidence base for pandemic impact on children and young people is very limited. Such evidence is urgently needed if adequate and responsive services, that can mitigate the long-term impact of the pandemic for children and young people can be established.

Factors influencing nurse spiritual care practices at the end of life: A systematic review

OBJECTIVES

The aim was to identify determinants of nurse spiritual/existential care practices toward end-of-life patients. Nurses can play a significant role in providing spiritual/existential care, but they actually provide this care less frequently than desired by patients.

METHODS

A systematic search was performed for peer-reviewed articles that reported factors that influenced nurses' spiritual/existential care practices toward adult end-of-life patients.

RESULTS

The review identified 42 studies and included the views of 4,712 nurses across a range of hospital and community settings. The most frequently reported factors/domains that influenced nurse practice were patient-related social influence, skills, social/professional role and identity, intentions and goals, and environmental context and resources.

SIGNIFICANCE OF RESULTS

A range of personal, organizational, and patient-related factors influence nurse provision of spiritual/existential care to end-of-life patients. This complete list of factors can be used to gauge a unit's conduciveness to nurse provision of spiritual/existential care and can be used as inputs to nurse competency frameworks.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Assessing Bladder Radiotherapy Response With Quantitative Diffusion-Weighted Magnetic Resonance Imaging Analysis

AIMS

Radiotherapy with radiosensitisation offers opportunity for cure with organ preservation in muscle-invasive bladder cancer (MIBC). Treatment response assessment and follow-up are reliant on regular endoscopic evaluation of the retained bladder. In this study we aim to determine the role of diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) analysis to assess bladder radiotherapy response.

MATERIALS AND METHODS

Patients with T2-T4aN0-3M0 MIBC suitable for radical radiotherapy were recruited prospectively to an ethics approved protocol. Following transurethral resection of the bladder tumour and prior to any treatment, magnetic resonance imaging including DWI was performed on a 1.5T system using b values of 0, 100, 150, 250, 500, 750 s/mm2. DWI was repeated 3 months after completing radiotherapy. Cystoscopy and tumour site biopsy were undertaken following this. The response was dichotomised into response (

RESULTS

Thirty-four patients were evaluated. Response was associated with a significant increase in ΔADC mean compared with poor response at ΔADCall (0.57 × 10-3 mm2/s versus -0.01 × 10-3 mm2/s; P < 0.0001) and ΔADCb100 (0.58 × 10-3 mm2/s versus -0.10 x 10-3 mm2/s; P = 0.007). A 48.50% increase in %ΔADCall mean was seen in response compared with a 1.37% decrease in poor response (P < 0.0001). This corresponded to a %ΔADCb100 mean increase of 50.34% in response versus a 7.36% decrease for poor response (P < 0.0001). Significant area under the curve (AUC) values predictive of radiotherapy response were identified at ΔADC and %ΔADC for ADCall and ADCb100 mean, 10th, 25th, 50th, 75th and 90th percentiles (AUC >0.9, P < 0.01). ΔADCall mean of 0.16 × 10-3 mm2/s and ΔADCb100 mean 0.12 × 10-3 mm2/s predicted radiotherapy response with sensitivity/specificity/positive predictive value/negative predictive value of 92.9%/100.0%/100.0%/75.0% and 89.3%/100.0%/100.0%/66.7%, respectively.

CONCLUSIONS

Quantitative DWI analysis can successfully provide non-invasive assessment of bladder radiotherapy response. Multicentre validation is required before prospective testing to inform MIBC radiotherapy follow-up schedules and decision making.

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Key Words

• Bladder cancer
• Diffusion-weighted MRI
• MRI
• Radiotherapy

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MESH Headings

• Diffusion Magnetic Resonance Imaging/methods
• Humans
• Magnetic Resonance Imaging
• Prospective Studies
• ROC Curve
• Urinary Bladder/diagnostic imaging
• Urinary Bladder Neoplasms/diagnostic imaging
• Urinary Bladder Neoplasms/pathology
• Urinary Bladder Neoplasms/radiotherapy

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Grants

• 28724 Cancer Research UK
• C33589/A19727 Cancer Research UK
• Department of Health
• C33589/A28284 Cancer Research UK

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Affiliation(s)

S Hafeez The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
M Koh The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
K Jones The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
A El Ghzal The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
J D'Arcy The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
P Kumar The Royal Marsden NHS Foundation Trust, London, UK
V Khoo The Royal Marsden NHS Foundation Trust, London, UK
S Lalondrelle The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
F McDonald The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
A Thompson The Royal Marsden NHS Foundation Trust, London, UK
E Scurr The Royal Marsden NHS Foundation Trust, London, UK
A Sohaib The Royal Marsden NHS Foundation Trust, London, UK
R Huddart The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK

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Mapping Local Failure Following Bladder Radiotherapy According to Dose

AIMS

To determine the relationship between local relapse following radical radiotherapy for muscle-invasive bladder cancer (MIBC) and radiation dose.

MATERIALS AND METHODS

Patients with T2-4N0-3M0 MIBC were recruited to a phase II study assessing the feasibility of intensity-modulated radiotherapy to the bladder and pelvic lymph nodes. Patients were planned to receive 64 Gy/32 fractions to the bladder tumour, 60 Gy/32 fractions to the involved pelvic nodes and 52 Gy/32 fractions to the uninvolved bladder and pelvic nodes. Pre-treatment set-up was informed by cone-beam CT. For patients who experienced local relapse, cystoscopy and imaging (CT/MRI) was used to reconstruct the relapse gross tumour volume (GTVrelapse) on the original planning CT . GTVrelapse D98% and D95% was determined by co-registering the relapse image to the planning CT utilising deformable image registration (DIR) and rigid image registration (RIR). Failure was classified into five types based on spatial and dosimetric criteria as follows: A (central high-dose failure), B (peripheral high-dose failure), C (central elective dose failure), D (peripheral elective dose failure) and E (extraneous dose failure).

RESULTS

Between June 2009 and November 2012, 38 patients were recruited. Following treatment, 18/38 (47%) patients experienced local relapse within the bladder. The median time to local relapse was 9.0 months (95% confidence interval 6.3-11.7). Seventeen of 18 patients were evaluable based on the availability of cross-sectional relapse imaging. A significant difference between DIR and RIR methods was seen. With the DIR approach, the median GTVrelapse D98% and D95% was 97% and 98% of prescribed dose, respectively. Eleven of 17 (65%) patients experienced type A failure and 6/17 (35%) patients type B failure. No patients had type C, D or E failure. MIBC failure occurred in 10/17 (59%) relapsed patients; of those, 7/11 (64%) had type A failure and 3/6 (50%) had type B failure. Non-MIBC failure occurred in 7/17 (41%) patients; 4/11 (36%) with type A failure and 3/6 (50%) with type B failure.

CONCLUSION

Relapse following radiotherapy occurred within close proximity to the original bladder tumour volume and within the planned high-dose region, suggesting possible biological causes for failure. We advise caution when considering margin reduction for future reduced high-dose radiation volume or partial bladder radiotherapy protocols.

Developing human biomonitoring as a 21st century toolbox within the European exposure science strategy 2020-2030

Human biomonitoring (HBM) is a crucial approach for exposure assessment, as emphasised in the European Commission's Chemicals Strategy for Sustainability (CSS). HBM can help to improve chemical policies in five major key areas: (1) assessing internal and aggregate exposure in different target populations; 2) assessing exposure to chemicals across life stages; (3) assessing combined exposure to multiple chemicals (mixtures); (4) bridging regulatory silos on aggregate exposure; and (5) enhancing the effectiveness of risk management measures. In this strategy paper we propose a vision and a strategy for the use of HBM in chemical regulations and public health policy in Europe and beyond. We outline six strategic objectives and a roadmap to further strengthen HBM approaches and increase their implementation in the regulatory risk assessment of chemicals to enhance our understanding of exposure and health impacts, enabling timely and targeted policy interventions and risk management. These strategic objectives are: 1) further development of sampling strategies and sample preparation; 2) further development of chemical-analytical HBM methods; 3) improving harmonisation throughout the HBM research life cycle; 4) further development of quality control / quality assurance throughout the HBM research life cycle; 5) obtain sustained funding and reinforcement by legislation; and 6) extend target-specific communication with scientists, policymakers, citizens and other stakeholders. HBM approaches are essential in risk assessment to address scientific, regulatory and societal challenges. HBM requires full and strong support from the scientific and regulatory domain to reach its full potential in public and occupational health assessment and in regulatory decision-making.

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012.  OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence.

MAIN RESULTS

We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.  Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence).  The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket  Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence).  A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

The Use of Human Biomonitoring to Assess Occupational Exposure to PAHs in Europe: A Comprehensive Review

Polycyclic aromatic hydrocarbons (PAHs) are among the chemicals with proven impact on workers' health. The use of human biomonitoring (HBM) to assess occupational exposure to PAHs has become more common in recent years, but the data generated need an overall view to make them more usable by regulators and policymakers. This comprehensive review, developed under the Human Biomonitoring for Europe (HBM4EU) Initiative, was based on the literature available from 2008-2022, aiming to present and discuss the information on occupational exposure to PAHs, in order to identify the strengths and limitations of exposure and effect biomarkers and the knowledge needs for regulation in the workplace. The most frequently used exposure biomarker is urinary 1-hydroxypyrene (1-OH-PYR), a metabolite of pyrene. As effect biomarkers, those based on the measurement of oxidative stress (urinary 8-oxo-dG adducts) and genotoxicity (blood DNA strand-breaks) are the most common. Overall, a need to advance new harmonized approaches both in data and sample collection and in the use of appropriate biomarkers in occupational studies to obtain reliable and comparable data on PAH exposure in different industrial sectors, was noted. Moreover, the use of effect biomarkers can assist to identify work environments or activities of high risk, thus enabling preventive risk mitigation and management measures.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Methylenediphenyl diisocyanate lysine conjugates in the urine of workers exposed to methylenediphenyl diisocyanate

Diisocyanates have long been a leading cause of occupational asthma. As control often relies on personal protective equipment and there is the potential for skin uptake, biological monitoring is often used to assess worker exposure. Current routine biological monitoring methods do not distinguish between a diisocyanate and the corresponding diamine exposure in urine samples; therefore, a specific urinary biomarker is desirable. Urine samples were obtained from a group of workers exposed to methylenediphenyl diisocyanate (MDI) where aerosol generation was unlikely. Lysine conjugates of MDI were extracted from urine by solid phase extraction; analysis was performed by liquid chromatography tandem mass spectrometry. Acetylated MDI-lysine (acMDI-Lys) conjugates were detected in 73% of samples tested from persons with exposure to MDI compared to 93% of samples that were positive for methylene dianiline (MDA) in hydrolysed urine. There was a weak but significant positive correlation between the two biomarkers (r² = 0.377). This is the first report detecting and quantifying acMDI-Lys in the urine of workers exposed to MDI, and acMDI-Lys may be a useful non-invasive biomarker in discriminating between MDI and MDA exposures.

Australian Patient Preferences for the Introduction of Spirituality into their Healthcare Journey: A Mixed Methods Study

While patients value engagement concerning their spirituality as a part of holistic healthcare, there is little evidence regarding the preferred way to engage in discussions about spirituality. This study investigated inpatient preferences regarding how they would like spirituality to be raised in the hospital setting. A cross-sectional survey was conducted with inpatients at six hospitals in Sydney, Australia (n = 897), with a subset invited to participate in qualitative interviews (n = 41). There was high approval for all proposed spiritual history prompts (94.0-99.8%). In interviews, the context dictated the appropriateness of discussions. Findings indicated a high level of patient acceptability for discussing spirituality in healthcare. Further research and more detailed analysis is required and proposed to be undertaken.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

A short-form version of the Australian English Communicative Development Inventory

Purpose: The Australian English Communicative Development Inventory (OZI) is a 558-item parent report tool for assessing language development at 12-30 months. Here, we introduce the short form (OZI-SF), a 100-item, picture-supported, online instrument with substantially lower time and literacy demands.Method: In tool development (Study 1), 95 items were drawn from the OZI to match its item distribution by age of acquisition and semantic categories. Five items were added from four other semantic categories, plus 12 gestures and six games/routines. Simulations computed OZI-SF scores from existing long-form OZI norm data, and OZI and projected OZI-SF scores were correlated. In an independent norming sample (Study 2), parents (n = 230) completed the OZI-SF for their children aged 12-30 months. Child scores were analysed by age and sex.Result: OZI-SF and OZI scores correlate highly across age and language development levels. Vocabulary scores (receptive, expressive) correlate with age and the median for girls is higher until 24 months. By 24 months, 50% of the sample combine words "often". The median time to OZI-SF completion was 12 minutes.Conclusion: Fitted percentiles permit working guidelines for typical (median) performance and lower cut-offs for children who may be behind on age-based expectations and/or at risk for a communication difficulty. The OZI-SF is a short-form of the OZI that has promise for research and clinical/educational use with Australian families.

A robust experimental and computational analysis framework at multiple resolutions, modalities and coverages

The ability to study cancer-immune cell communication across the whole tumor section without tissue dissociation is needed, especially for cancer immunotherapy development, which requires understanding of molecular mechanisms and discovery of more druggable targets. In this work, we assembled and evaluated an integrated experimental framework and analytical process to enable genome-wide scale discovery of ligand-receptors potentially used for cellular crosstalks, followed by targeted validation. We assessed the complementarity of four different technologies: single-cell RNA sequencing and Spatial transcriptomic (measuring over >20,000 genes), RNA In Situ Hybridization (RNAscope, measuring 4-12 genes) and Opal Polaris multiplex protein staining (4-9 proteins). To utilize the multimodal data, we implemented existing methods and also developed STRISH (Spatial TRanscriptomic In Situ Hybridization), a computational method that can automatically scan across the whole tissue section for local expression of gene (e.g. RNAscope data) and/or protein markers (e.g. Polaris data) to recapitulate an interaction landscape across the whole tissue. We evaluated the approach to discover and validate cell-cell interaction in situ through in-depth analysis of two types of cancer, basal cell carcinoma and squamous cell carcinoma, which account for over 70% of cancer cases. We showed that inference of cell-cell interactions using scRNA-seq data can misdetect or detect false positive interactions. Spatial transcriptomics still suffers from misdetecting lowly expressed ligand-receptor interactions, but reduces false discovery. RNAscope and Polaris are sensitive methods for defining the location of potential ligand receptor interactions, and the STRISH program can determine the probability that local gene co-expression reflects true cell-cell interaction. We expect that the approach described here will be widely applied to discover and validate ligand receptor interaction in different types of solid cancer tumors.

Temporal and Spatiotemporal Arboviruses Forecasting by Machine Learning: A Systematic Review

Arboviruses are a group of diseases that are transmitted by an arthropod vector. Since they are part of the Neglected Tropical Diseases that pose several public health challenges for countries around the world. The arboviruses' dynamics are governed by a combination of climatic, environmental, and human mobility factors. Arboviruses prediction models can be a support tool for decision-making by public health agents. In this study, we propose a systematic literature review to identify arboviruses prediction models, as well as models for their transmitter vector dynamics. To carry out this review, we searched reputable scientific bases such as IEE Xplore, PubMed, Science Direct, Springer Link, and Scopus. We search for studies published between the years 2015 and 2020, using a search string. A total of 429 articles were returned, however, after filtering by exclusion and inclusion criteria, 139 were included. Through this systematic review, it was possible to identify the challenges present in the construction of arboviruses prediction models, as well as the existing gap in the construction of spatiotemporal models.

DETECTION phase II/III trial: Circulating tumor DNA–guided therapy for stage IIB/C melanoma after surgical resection

TPS9603

Background: Circulating tumor DNA (ctDNA; the tumor derived fraction of circulating free DNA in the blood) is a well recognized, minimally-invasive biomarker of tumor burden/progression in many cancers. We have previously shown in retrospective and prospective cohorts of patients with melanoma that ctDNA analysis of serial blood samples following curative intent surgery can identify minimal residual disease (MRD) or molecular relapse. The majority of patients with resected stage II melanoma do not recur, therefore better strategies to identify high risk patients are required. Furthermore, a consistent finding in studies of immune therapy in stage IV melanoma is that patients with small volume disease have the best outcome. We aim to test whether early relapse can be identified by ctDNA analysis and acted upon in a clinically relevant timeframe, and if early treatment of molecular recurrence with immune therapy improves outcomes for patients with resected stage IIB/C melanoma. Methods: We designed a phase II/III multicenter study across 21 UK and 4 Australian sites with a tumor informed approach employed for ctDNA detection. Droplet digital assays for BRAF/NRAS/TERT promoter mutations were validated for sensitive ctDNA detection across two accredited clinical testing laboratories. Patients with stage IIB/C melanoma, BRAF/NRAS/TERT promoter mutant cutaneous melanoma, ECOG 0/1, adequate organ function, with complete resection (including sentinel lymph node biopsy) performed within 12 weeks and radiological/clinical disease-free status confirmed within 4 weeks prior to registration, no prior immune/targeted therapy will be followed up with blinded ctDNA sampling in addition to clinical follow-up. Patients with ctDNA detected will be randomised 1:1 in a double blind fashion to continue routine follow-up with investigators choice treatment if they develop disease recurrence, or unblinded and treated with nivolumab 480mg IV Q4-weekly. Primary objectives include i) whether MRD/molecular relapse following curative intent surgery can be identified earlier than clinical relapse, ii) whether early treatment of molecular recurrence with nivolumab improves overall survival. 1050 patients are planned to be enrolled. The study opened in the UK in November 2021 and will open in Australia in Spring 2022. Clinical trial information: NCT04901988.

Student perceptions of faculty caring in online nursing education: A mixed-methods study

BACKGROUND

As the prevalence of online nursing education increased, so did the need for faculty to understand student perceptions of faculty behaviors that demonstrate caring and promote student success. Literature from both education and nursing journals supported this study.

OBJECTIVES

Primary objectives were to identify how the value of caring is made visible in online learning, to understand how students prioritized faculty caring behaviors and to identify any significant differences in perceptions related to student demographics. A secondary objective was to provide professional development tools for faculty who teach nursing students in the online environment.

DESIGN

Mixed methods.

SETTING

A College of Nursing within a large public university in the Southeastern United States.

PARTICIPANTS

One hundred and forty-one (141) nursing students pursuing graduate degrees (MSN or DNP) participated in the student survey and 15 participated in the focus groups/interviews; 28 faculty members responded to the survey.

METHODS

A validated survey tool was used to identify how students prioritized faculty caring behaviors. Facilitator-led focus groups were used to gain additional insights. Faculty members were surveyed to compare faculty and student priorities. Descriptive and correlational analyses were performed.

RESULTS

Graduate nursing students perceived a course that is well-designed, with clear instructions and communication, and a supportive environment, to be evidence of faculty caring. There were significant differences in student responses when analyzed by demographic characteristics such as gender and race. Student perceptions aligned with previous research on this topic; faculty and student perceptions differed in some areas.

CONCLUSION

Quantifying graduate student perceptions about faculty caring behaviors provided information that is used for faculty professional development. Further research is needed to explore perceptions of faculty caring in different student populations. Multi-site studies to explore race and gender differences in perception are also recommended.